Diverticulosis: Those Confusing Pockets

As a gastroenterologist I spend a lot of time performing colonoscopies.  As a result, I spend a lot of time talking with patients after the procedures about things I find inside their colon.  Common findings on colonoscopies include colon polyps, hemorrhoids, and diverticulosis.  Multiple times a day I find myself discussing diverticulosis and trying to dispel common misconceptions about it.  There is a lot of confusion about diverticulosis.  “You mean I can’t eat popcorn anymore?” is something patients ask me.  This is not true (see below).  As somebody who loves popcorn, I would never want to deny somebody the chance to eat popcorn.  Let’s discuss.

What is Diverticulosis?  Diverticulosis is the presence of pockets in the colon.  This is due to a weakness in the wall of the colon.  This is seen in over half colonoscopies (50%) and increases with age.  Estimates are that 50% of people over 50 have diverticulosis; 60%of people over 60 have diverticulosis; and 70% of people over 70 have diverticulosis.  Many people with these pockets do not have symptoms or GI concerns.

What is Diverticulitis:?  Diverticulitis is when 1 of the pockets becomes inflamed and infected.  Only 4% of patients with diverticulosis will get diverticulitis.  Even though this number is rather low, if you think about it, if half of people have diverticulosis, and 4% of people with diverticulosis eventually get diverticulitis, this means that about 2% of people will have an episode of diverticulitis sometime during their lifetime.  This is why everyone seems to know at least one person who has had issues with diverticulitis.  Not all attacks of diverticulitis are severe.  While some may require surgery most resolve with antibiotics.  (Clin Gastroenterol Hepatol. 2013;11)

Therefore:

– OSIS:  Presence of the pockets.  Does not mean a problem.

– ITIS:  Means inflammation or infection of the pockets.

Diverticulitis typically resolves with a bland diet and antibiotics.  Severe cases that result in uncontrollable abdominal pain, inability to eat, inability to pass gas or stool, or development of an abscess can require surgery and hospitalization. 

There is reported higher risk of colon cancer in patients who have had diverticulitis, therefore a colonoscopy is typically advised 6–8 weeks after having an episode of diverticulitis if the patient has not had a colonoscopy in over a year.  (Ann Surg. 2017;265(5):954.)  It is unclear as to why this is the case.  Sometimes colon cancers and diverticulitis can look similar on a CT scan.  

What is symptomatic diverticular disease.? When the patient has symptoms from the narrowing caused by diverticulosis and there is no evidence of inflammation.  Often causes issues with constipation and abdominal cramps.  Very similar to irritable bowel syndrome. 

Many patients ask:  “How can I prevent problems from the pockets?”.

For patients without any symptoms, nothing really needs to be done.  Healthy lifestyle advice in regards to diet, exercise, and maintaining a healthy body weight is always suggested.  I often say, “If I find diverticulosis, I tell you to eat more fruits and vegetables.  If I don’t find diverticulosis, I tell you to eat more fruits and vegetables.”

Smoking, obesity, lack of dietary fiber, and lack of physical activity are all associated with problems from diverticulosis.

Nuts and seeds?  Everyone seems to have an elederly relative who would not eat berries or popcorn.  This is based on old misconceptions and medical myth.   A large medical research study showed that nuts and seeds do not cause episodes of diverticulitis.    (JAMA. 2008;300(8):907)  .In fact, high-fiber diets have been shown to be preventative of diverticular disease.  There may be a subset of patients who have trouble with high residue foods.  I typically advise patients that see a direct correlation to things like nuts and popcorn and attacks of diverticulitis to avoid these foods.  If these foods are generally not a bother, there should be no restriction on the consumption of high amounts of roughage, seeds, nuts.

Eating the jumbo bucket of movie popcorn and getting sick does not mean you have diverticulitis.  It means you ate way to much popcorn.  Moderation in all things is best.

Fiber?  Increasing dietary fiber or fiber supplementation is typically advised for patients with symptomatic diverticulosis.  This is based on the fact that there is an inverse correlation between fiber intake and complications from the diverticula. 

Probiotics?  There is some medical evidence, albeit week evidence that probiotic supplementation may also help with symptoms from diverticular disease.  (Therap Adv Gastroenterol. 2013 May; 6(3): 205–213.)   If a patient has symptoms from diverticular disease I do advise trying probiotics.  If a trial of probiotics for 2–4 weeks tends to help with the symptoms I advise continuing them.  If the trial of probiotics does not help with the symptoms I typically advise stopping them as the evidence is not strong.  Lactobacillus probiotics have been studied the most for this.

Hopefully this helps explain those pesky pockets in the colon.